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US HAEA Scientific Registry
Research for a Cure

The information you provide will be kept strictly confidential. You must complete all fields in the form to submit it.

First Name: 
Last Name: 
Maiden Name: 
(if applicable)
 
Gender:  Male Female
 
Address: 
 
 
City: 
State:    Zip Code: 
 
Home Phone Number:  Digits only - no spaces, dashes, or parenthesis
Cell Phone Number:  Digits only - no spaces, dashes, or parenthesis
E-mail address: 
Secondary E-mail address: 
 
Date of Birth: 
 
Diagnosis: 
 
Ethnicity: 







 
Are you a member of the US HAE Association?  Yes No
Do you have a blood relative with known HAE?  Yes No
Do you have a blood relative with HAE who is currently participating in this research project?  Yes No
 
What medication(s) do you currently use?











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Have questions?
Contact Registry Administrator
Janet Long

(866) 798 - 5598

US HAEA Scientific Registry
10560 Main Street, Suite PS40
Fairfax City, VA 22030


Scientific Registry